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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTij DEPARTMENT <br /> SERVICE REQUEST <br /> Tyim of Busines r Prope r FACILITY ID# SERVICE REQUEST# <br /> 7 <br /> O R I OPERATOR -- <br /> P CHECK If BILLING ADDRESS <br /> FACILITY NAME O ///���•�•••l V <br /> SITE ADDRESS� , <br /> Vt✓ Street Number rection r Y� " J Ze �' <br /> HOME or MAILING ApWss Diffe nt from Site A ress) <br /> Street Number k Street Name <br /> CITY STATE ZIP <br /> ( /A � 23 <br /> PH ON #'I ExT• APN* LAND USE APPLICATION III <br /> ) 7 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTO f LbIL CHECK ff BILLING ADDRESS <br /> BUSINESS NAME %r1/i PHONE# ExT• <br /> HOME or MAILING DDRESS _ FAX# <br /> CITYSTATE <br /> A a <br /> BILLING ACKNOWLED EMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this a m <br /> ication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, T TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ` DATE: / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BlLLLNG PARTY.proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE Of SERVICE REQUESTED: �/t LJL RECEIVED <br /> COMMENTS: <br /> JAN 3 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: - -21 <br /> I <br /> G.- <br /> ASSIGNED TO: '� I 4' 1 ti EMPLOYEE#: 2, 5; DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: r`I �;� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD SR FORM(Golden Rod) <br /> REVISEDSED 11/1 11/17/2003 <br />